Patient selection in ambulatory anesthesia - an evidence-based review: part I

To identify and characterize the evidence supporting decisions made in the care of patients with selected medical conditions undergoing ambulatory anesthesia and surgery. Conditions highlighted in this review include: the elderly, heart transplantation, hyper-reactive airway disease, coronary artery disease, and obstructive sleep apnea.

A structured search of MEDLINE (1966-2003) was performed using keywords for ambulatory surgery and patient condition. Selected articles were assigned a level of evidence using Centre for Evidence Based Medicine (CEBM) criteria. Recommendations were also graded using CEBM criteria.

The elderly may safely undergo ambulatory surgery but are at increased risk for hemodynamic variation in the operating room. The heart transplant recipient is at increased risk of coronary artery disease and renal insufficiency and should undergo careful preoperative evaluation. The patient with reactive airway disease is at increased risk of minor respiratory complications and should be encouraged to quit smoking. The patient with coronary artery disease and recent myocardial infarction may undergo ambulatory surgery without stress testing if functional capacity is adequate. The patient with obstructive sleep apnea is at increased risk of difficult tracheal intubation but the likelihood of airway obstruction and apnea following ambulatory surgery is unknown.

Ambulatory anesthesia is infrequently associated with adverse outcomes, however, knowledge regarding specific patient conditions is of generally low quality. Few prospective trials are available to guide management decisions.